Leishmaniasis: pentavalent antimonials still primary therapy

11 The latest advance in NSAID research is the development of selective cyclo-oxygenase type 2 (COX-2) inhibitors. The COX-2 isoenzyme is thought to be responsible for prostaglandin production at sites of inflammation. Selective inhibition of the COX-2 isozyme seems to have anti-inflammatory and analgesic actions without gastrointestinal toxicity, but the clinical relevance of this remains to be determined)9] Topical NSAIDs may also be useful in the short-term management of acute low back pain, but are more expensive than oral preparations. Plasma NSAID concentrations are considerably lower after topical compared with oral administration, thus minimising systemic adverse effects.l IO ] However, such adverse effects have been reported after topical NSAIDs. The use of oral NSAIDs in conjunction with topical NSAIDs available over-thecounter should be discouraged. Muscle relaxantslanxiolytics Painful muscle spasm is sometimes associated with acute low back pain, and a muscle relaxant such as carisoprodol or orphenadrine citrate t in combination with an analgesic can give symptomatic relieO I ,3] These agents can be associated with behavioural alterations including sedation and paradoxical agitation; they also have some potential for abuse)l] Diazepam and other benzodiazepines have muscle relaxant properties, and may be particularly useful for short-term treatment when a definite anxiety state is a significant factor in low back painJ3,6] It should be given in the lowest dose for the shortest timeJ3] Benzodiazepine therapy for a maximum of I week may also be useful in patients who have difficulty sleeping because of back pain)4] Antidepressants Antidepressants can elevate mood and may increase pain tolerance in depressed patients with chronic low back pain. Amitriptyline is more effective than other antidepressants for relieving back pain, but causes more adverse effects such as dry mouth, constipation and drowsiness)3] A typical dosage regimen for amitriptyline would be 10 to 25mg at night, gradually increasing up to 100 to 150mg until benefits are achieved or adverse effects occur. The onset of analgesia may take up to 3 months)3] Corticosteroids There is little evidence to support the use of local or epidural injections of corticosteroids to relieve lower back pain.[3,4] Corticosteroids should not be used in patients with back pain due to osteoporosis, since they may increase bone lossV] Other therapies Bedrest is important in the initial management of low back pain)1 ,4, II] However, too much bedrest is counterproductive. Two days in bed is as good as 2 weeks)3] In the recovery period, it is better to mobilise and experience some back pain, than risk the complications of bedrest and the sedating effects of too many drugs)3] Other therapeutic interventions that may be of use in the management of low back pain include specific exercises, manual therapy and manipulation, corsets, transcutaneous electrical nerve stimulation, and physiotherapy) I ,4, II] t Orphenadrine citrate has been withdrawn from the Spanish market; amphotericin B and pentamidine are not available in Denmark. 1172·0360/9510006·00 /l1$0 1.00 ©Adis International Limited. All rights reserved References I. Vukmir RB. Low back pain: Review of diagnosis and therapy. Am J Emerg Med 1991 Jul; 9 (4): 328-35 2. Lahad A, Malter AD, Berg AO, et al. The effectiveness of four interventions for the prevention of low back pain. JAMA 1994 Oct 26; 272 (16): 1286-91 3. Porter RW, Ralston SH. Pharmacological management of back pain syndromes. Drugs 1994; 48 (2): 189-98 4. Frank A. Low back pain. 8MJ 1993 Apr 3; 306: 901-9 5. McKenzie R, Poulter D. The management of work-related back pain. Patient Manage NZ 1993 Apr; 27-8 6. British National Formulary No. 28. London: The Pharmaceutical Press, 1994; 175,177,363-5 7. Thurel C, Bardin T, Boccard E. Analgesic efficacy of an association of 500-MG paracetamol plus 30-MG codeine versus 400-MG paracetamol plus 30-MG dextropropoxyphene in repeated doses for chronic lower back pain. Curr Ther Res 1991 Oct 4; 50 (4): 463-73 8. Turturro MA, Paris PM. Oral narcotic analgesics. Choosing the most appropriate agent for acute pain. Postgrad Med 1991 Nov 15; 90 (7): 89-95 9. Battistini B, Bakhle YS. COX-I and COX-2: Toward the development of more selective NSAIDs. Drug News Perspect 1994 Oct; 7 (8): 501-12 10. White S. Topical non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment of inflammatory musculoskeletal disorders. Prostaglandins Leukot Essent Fatty Acids 1991; 43: 209-22 II. Back pain: The problem and its treatment. Pharm J 1994 Oct 8; 253: 497-8 Leishmaniasis: pentavalent antimonials still primary therapy Pentavalent antimonials remain the primary therapy for all forms of leishmaniasis, despite a plethora of alternative agents having been investigated. However, amphotericin Bt and pentamidine t appear to be suitable options in antimonial-refractory disease, and have been evaluated as first-line options also. Amphotericin B may become the more attractive option as experience with the better-tolerated liposomal formulations accumulates. In addition, oral agents such as the azole antifungals and allopurinol have shown promise. Another novel approach is to modulate the immune system in order to prevent or treat the infection. Leishmaniasis Leishmaniasis is caused by various protozoa of the genus Leishmania, with the manifestations of the disease differing according to the species of parasite involved (see table I). The infection is transmitted to humans from animals such as rodents and dogs following sandfly bites. This disease is endemic to many tropical and subtropical countries, including those in Central and South America, Africa and the Middle East. Travellers to endemic regions may return to their country of residence with the infection. For example, some US military personnel acquired the infection during postings in the Middle East.[l] Ip addition, it appears that the disease has been acquired in Texas, US)I] Leishmaniasis is also emerging as an important infection among immunocompromised patients, and visceral disease is now common among HIV-infected patients in Mediterranean countries.l 5] Thus, physicians the world over should maintain an index of suspicion for leishmaniasis, particularly among patients who have visited endemic regions in the last 2 Vol. 5, No.6; April 3, 1995 Table 1. Characteristics of Leishmania infection[1·4) Form of disease Disease characteristics Leishmania species Old World cutaneous (Oriental sore) Papules/nodules at site of inoculation enlarge and then ulcerate Depending on the species of parasite, there may be single ar multiple lesions that heol spontaneously within a year or in up to 3 years Rarely forms chronic, nonheol ing sores L. major, L Iropica, L aelhiopica, L infanlum New World cutaneous (Oriental sore, Chiclero's ulcer) As above, although Chiclero's ulcer may persist for up to 20 years Chiclero's ulcer of the e (...truncated)